BSNR Annual Meeting 2009

Our thanks to the Nottingham team who put on a fabulous show. The first night at the castle was held in the midst of the city’s outstanding art collection. The Asian / Nottingham fusion food was delicious – the stir fried beef was Michelin 3 star! The meal was followed by an obligatory trip to the beer festival. Not such a good idea.

The highlights of the opening day included a memorable walk around tumours the skull base by Vincent Chong – a subject he managed to make very simple. There are congenital lesions – NFI and fibrous dysplasia (whenever a lesion looks odd, think “fibrous dysplasia”). Acquired lesions on the other hand should be thought of as if they were occurring around the knee! (Now all rules have exceptions and in the skull base this is the meningioma, which doesn’t happen in the knee due to the absence of meninges).

In Paediatrics we learnt from Nottingham that (1) Benign Expansion of the Subarachnoid Space (BESS) is benign – a self limiting condition, not, thankfully, associated with subdurals and also not that rare, with an incidence of 1 in 300; and (2) low dose CT is the way to go for repeated scans that children with shunts often require – by reducing the mA down to ~50, the Preston team achieved a 90% dose reduction but maintained adequate image quality.

In the Spinal Session, Debbie Annesley-Williams presented some very elegant research which measured pressures in the spine: fractures of the vertebral bodies increase the load on the apophyseal joints by an average of 170%, which explains the remarkable placebo response in the vertebroplasty trials since those that received placebo had anaesthetic to their facet joints. In order to restore normal stress distribution a 7 cm3 cement injection to the vertebral body was required. Debbie was awarded the Burrows Prize for her work.

The Vascular Imaging session was dominated by 3T imaging centres. Glasgow and Nottingham presented interesting work which further characterises carotid plaque: plaque haemorrhage, which encroaches the vessel lumen, strongly predicts cerebrovascular events. Gillian Potter from Edinburgh presented a revue of how researchers use the term “lacunar” – a very woolly term which reminded me of Voltaire’s dictum “if you wish to converse with me, first define your terms.” Rather frustratingly, particularly for Dr Clifton, no concrete definition was offered.

There were many interesting papers on brain tumours. ADC maps don’t help grade tumours but enhancing fraction measured from dynamic contrast enhanced MR may predict survival. I have always been surprised that Pathology, rather than imaging, is used by clinicians as the gold standard for grading tumours. I know it’s traditional, but pathologists see only a tiny piece of the tumour whereas we can see the whole caboodle and now also know all sorts of new things, like tumour vascularity, diffusion characteristics, and, over a couple of scans, how it is ticking. So what we need is a trial comparing survival against pathologic grade and radiologic grade. Then maybe we can refine management further and try to predict which radiologically graded tumours will respond to which treatments – next BSNR perhaps. Dr Mills from Manchester was awarded the prize for the best presentation by a junior doctor for her work on enhancing fractions.

The James Bull Lecture was a delight. Colin Blakemore endeared himself to his audience by remaining uncontactable until 10 minutes before he was due to speak – he was preparing his talk in his bedroom. He could almost be an honorary neuroradiologist just for that. We were taken through a history and philosophy of the brain. Descartes believed that sight was projected into an inner eye, or vesicle, in the pineal gland â€“ shades of Gilbert Ryles “ghost in the machine” or even Cartesian dualism. We were brought up-to-date via the single retinal cell electrical recordings of Hubel and Weisel and finally reached Professor Blakemore’s own work performing functional imaging on blind subjects. Fascinatingly, for these blind subjects, the visual cortex is used for touch and the other senses that compensate for sight. So it is not surprising that those who have their sight restored later in life perform so badly. It was a masterly overview of neurophysiological optics!

We were addressed by Marco Leonardi, President of the ESNR. He envisages a Federation of Neuroradiology Societies of Europe. It remains to find out what the implications are of this. Tom Booth gave a slightly depressing paper for which he had sent a questionnaire to PI’s using volunteers for their MR research. The clinical governance for these studies is clearly sadly lacking with many centres not having contingency plans for when an incidental finding is found, and few inform their volunteers of the potential risks of having a scan e.g. not being able to get insurance. A meeting is being organised by Professor Wardlaw (announcement to follow) at which it is hoped a code of practice will be drawn up.

The best of the meeting was kept to last – Intervention (of course). It wasn’t all new and sexy ways to retrieve bits of metal you’ve misplaced. Andy Molyneux and Phil White have meta-analysed the recent HELPS and Cerocyte trials, with ISAT, and happily confirmed that interventionalists of today are at least as good again as the interventionalists in ISAT, when compared to surgery for treating aneurysms.

Dr Booth (left), Dr Molyneux (center) & Dr White (right)

The Annual Business Meeting was not quite the usual rambunctious affair of old – must be the calming influence of our secretary Mary (minutes will be circulated). The sub-committees have really taken off. The Standards Committee is rewriting much of “Effective Neuroradiology” and hopefully will produce a reference document that will help neuroradiologists counter some of the grosser insanities of management. They are also setting up a group that will be prepared – if asked – to go into a failing department and give a report. This was viewed very positively as a service that could well be useful to departments that are hitting their heads against the proverbial wall. The Academic Subcommittee has really built up a head of steam. It aims next year to appoint a du Boulay Travelling Professor and to hold a Spring Academic Meeting. Finally the Education and Training Committee is also moving ahead, developing a curriculum prior to taking forward a 3 year training scheme for Neuro-intervention.

The 2009 BSNR dinner had the best food (Ivan eat your heart out) and the worst speeches in memory, but that didn’t seem to spoil a great evening. We all stood up for the Queen and for our Society, now proudly celebrating its 40th year.